PRACTICE 1

PRACTISE 2 (If applicable)

DETAILS OF PARTNERS/ LOCUM PRACTITIONERS

PRACTICE DETAILS - NURSING PERSONNEL

FEES

(a) For completion in respect of ALL applications.
(b) Questions raised and answers given to be read and interpreted as being solely applicable to MEDICAL AID PATIENTS OR MEMBERS who are associates of AHFoZ.
(C) Where the agreed tariff of fees or applicable AHFoZ scale of awards is not accepted and adhered to, a system of direct payments by medical aid societies will not be offered or entered into.
(d) A combination of CASH and DIRECT PAYMENTS will not be accepted.

Tariff of Fees:

Payment/Claiming Procedure:

DECLARATION
I/We, the undersigned, hereby declare that the information contained on the application form is correct and duly authorise the Association of Healthcare Funders of Zimbabwe (AHFoZ) to disseminate relevant information to its member societies.

I/We undertake to advise AHFoZ of any changes to my/our practice profile in the event that such changes may occur. I/We further declare that I/We will abide by the rules governing the Provider Numbers.

I/We acknowledge that any activities associated with fraud, waste and abuse will attract disciplinary measures as set out in the rules governing Provider Payee Numbers.